NEWS FOCUS: Refugees and asylum seekers may be in poor health when they reach Britain.But after a period of NHS care the health of some has actually deteriorated, reports Paul Smith

The sign reads 'no refugees or asylum seekers'. It could have been posted 40 years ago, when Britain was entangled in the reflex bigotry of the post-war era.

It is certainly not the sentiment you expect to find in our tolerant 21st-century multi-cultural society.

But the sign was posted recently outside a GP surgery in south-east London.

As the debate over asylum seekers continues to excite the tabloid headline writers, public services, including the NHS, are dealing with the ground-level issues.Many managers fight shy of getting caught up in the politics. The principle is simple:

the service is open to all, free at the point of access.

This - even under the law - applies to asylum seekers too.

But in the context of scarce resources, high workload and an apparent lack of central co-ordination - as witnessed by the surgery poster - it quickly becomes something few can ignore.

This month Amnesty International held a conference in London to discuss what the NHS should do to support refugees. From those working in the field, 'a lot more' seemed to be a constant reply.

Jane Cook is leader of the refugee clinical team for Lambeth, Southwark and Lewisham health authority, dealing with around 32,000 asylum seekers and refugees.

Much of her work is providing medical care in accommodation blocks where refugees are held when they first enter the country.

She believes that political hype over the nature of immigrants gets in the way of ensuring that their healthcare needs are met:

'Of course there are the ideas that these people are scroungers.

'I have to deal with those who have been raped and tortured, children who have seen members of their family die and have gone through real horrors in transit to get here. Sadly, It is true to say that even some GPs find it hard to understand that.'

Accommodation centres usually hold refugees for between five and 14 days before they are dispersed by the National Asylum Seekers Support Service (NASS) to 13 areas of the UK. The aim is to relieve the pressure on services in the South East and London. So far some 25,000 people have been 'processed' - often simply by being given a destination and a bus ticket to get there.

One problem has been lack of communication. NASS has often failed to inform HAs or councils of the refugees' arrival. The situation is made worse when they end up being pushed into private accommodation.

Without the ability to track where they have gone, HAs can find refugees slipping through the welfare system altogether.

Facing the usual mix of poverty, poor diet, psychological trauma, bad housing and lack of social networks, the results are shaming.

Despite Britain's first-world high-tech society, the health of most asylum seekers, according to Ms Cook, actually declines once they arrive in the UK.

The attitude of a minority of GPs has not made it any easier for refugees in need of help. Refugees in the UK are legally entitled to NHS treatment.Yet when they have attempted to register, some GPs have refused. Others have stuck them on temporary registers which deny patients access to screening services.

Concerns about funding and lack of interpreters have been among the reasons - also workload pressures.

Taking on a fresh influx of refugees whose consultations often take twice as long due to language barriers has not helped GPs struggling to tackle the health problems of local people already living in highly deprived areas.

It is this which has led to resentment among local patients who end up facing long waits.

In response, many HAs have set up a series of specialist services through personal medical services.

Among the best, according to delegates at the Amnesty conference, have been those at Newcastle and North Tyneside HA, which has dealt with 3,000 refugees in the last year.All its pilots have been based on different delivery models.

Some teams involve health visitors, nurses and support workers, others are specialist refugee practices.

Yet none has been supported by specific funding - instead they have been put together with PMS 'growth money', says David Chappel, the HA's consultant in public health medicine.

'Dealing with refugees is a difficult issue, ' he said.

'Yet the Department of Health doesn't seem to have acknowledged the problem.

'There is a role for them in terms of issuing guidance. Some sort of co-ordination is needed with bodies like NASS, so we have a co-ordinated approach.

'There have been examples of refugees turning up in different areas, and neither local authorities nor HAs have been informed.'

He added: 'I think it would be a good idea if our models could be evaluated in some way. This has not happened but it is important that we find out what works and spread good practice.'

Many working with refugee healthcare have called for DoH action.

One simple idea is to publish information leaflets detailing in different languages how refugees access the system in the first place.

This might prevent them from turning up at accident and emergency departments for problems that should be dealt with at primary care level.

Last week the DoH said: 'Our officials and Home Office/ NASS are already exploring how we might provide more coherent and joined-up arrangements to notify local partners in advance about dispersal of asylum seekers.

'Lots of effective models and practice are going on in the field to meet the health and social care needs of asylum seekers.

The DoH is undertaking work to gather and disseminate this across the country.'

For Jane Cook, a more straightforward response is required: 'There needs to be one person at the DoH to take a lead on this issue.'